FUNDAMENTAL PRINCIPLES
Equipment for airway
management
Andrew Laurie
Jamie Macdonald
Abstract
Airway management provides gas exchange, protects the lungs from
injury and permits treatment. This requires safe, effective and reliable
use of equipment, often in combination. A management plan with
backups is essential, but a sequence of logical plans forming an
airway management strategy is better. Correct equipment use needs
correct knowledge, skill and attitudes. There are five approaches to
airway management in which equipment is used: facemask ventilation
with adjuncts, use of supraglottic airway devices, tracheal intubation
with a variety of laryngoscopes (including the flexible fibreoptic bron-
choscope), front of neck (transtracheal) access using cricothyroidot-
omy or tracheostomy and airway clearance with suction or foreign
body removal. Tracheal tubes and aids for placement are described.
Keywords Airway; bougie; cricothyroidotomy; flexible fibreoptic
bronchoscope; laryngeal mask airway; laryngoscope; optical stylet;
tracheal intubation; tracheal tube; tracheostomy
Royal College of Anaesthetists CPD Matrix: 1C01, 1C02
The aim of airway management is to facilitate gas exchange (i.e.
delivery of oxygen to, and removal of carbon dioxide from, the
lungs) and to protect the lungs from aspiration of foreign
material.
The 4th National Audit Project (NAP4) notes that all anaes-
thetists should employ ‘an airway management strategy’, a ‘co-
ordinated logical sequence of plans’. As such, practitioners need
to be competent in the use of a variety of different pieces of
equipment in order to formulate and execute ‘plan B’.1 This
notion of planning for failure is core to the Difficult Airway So-
ciety (DAS) guidelines for the management of the unanticipated
difficult tracheal intubation.2
Even the most simple of strategies involves a variety of
equipment, often used in sequence, and therefore functional
compatibility is important (e.g. a tracheal introducer or stylet
must fit the chosen tracheal tube). Moreover, all equipment must
have standard dimensions when matching is needed (e.g.
adoption of standard 15/22 mm connectors to allow connection
to breathing systems). All equipment must be biologically
compatible and supplied sterile.
Andrew Laurie MB ChB FRCA is a Specialty Trainee in Anaesthesia and
Intensive Care Medicine at Aberdeen Royal Infirmary, Scotland, UK.
Conflicts of interest: None declared.
Jamie Macdonald MB ChB FRCA FFICM is a Consultant Anaesthetist at
Aberdeen Royal Infirmary, Scotland, UK. Conflicts of interest: None
declared.
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Learning objectives
After reading this article, you should be able to:
C list the approaches to airway management, giving examples of
equipment for each
C discuss the types of supraglottic airway devices available,
knowing their strengths and weaknesses
C discuss the types of laryngoscopes, tracheal tubes and aids to
intubation available
The detection of expired carbon dioxide as a marker of airway
patency is vital; capnography is considered an essential monitor
in the latest guidelines from the Association of Anaesthetists of
Great Britain and Northern Ireland (AAGBI).
Recently, there has been an increase in the number and type
of equipment, especially supraglottic airway devices (SADs) and
various laryngoscopes.3 In many cases, there is little clinical
evidence to support their use. In response, DAS has introduced
the ‘ADEPT’ scheme for device evaluation, which stipulates that
a device be considered for purchase following evaluation of ev-
idence at ‘level 3’, a case series.4
There are four broad stages of airway management, listed in
order of invasiveness:
1. Facemask ventilation (with or without adjuncts).
2. Supraglottic airway devices.
3. Tracheal access from above the vocal cords.
4. Tracheal access from below the vocal cords.
There is also a fifth stage, airway clearance, which may occur
at any point and so does not fit neatly into the above list.
These stages may be used alone, or in a sequence, planned or
unplanned. Similarly, one stage may be used to facilitate another
(e.g. using a supraglottic airway to permit tracheal intubation).
Facemask ventilation (FMV) with adjuncts
A facemask consists of a mount typically connected to a
breathing system via an angle piece, a body and an edge (pre-
formed or inflatable cuff). This technique requires the practi-
tioner to possess the technical skill to maintain the patient’s head
and neck in an optimal position and to keep a good seal between
mask and face.
The Han grading of FMV5 is:
0: Not attempted
1: Ventilated by mask
2: Ventilated, adjuncts needed
3: Ventilated, difficult (two-handed, adjuncts needed)
4: Impossible
Adjuncts include oropharyngeal (‘Guedel’) and nasopharyn-
geal airways.
Supraglottic airway devices (SADs) (Figure 1)
These occupy the middle ground between FMV and endotracheal
intubation regarding anatomy, security and invasiveness. There
are over 15 devices, single-use or reusable, but all are inserted
blindly. There is no clear evidence as to which device is clinically
superior.
1 Ó 2018 Published by Elsevier Ltd.
 FUNDAMENTAL PRINCIPLES

a
c

d
e

g
e

Figure 1 Supraglottic airway devices (single use). (a) Classic LMA (AmbuÒ AuraStraightÔ disposable laryngeal mask). (b) Flexible LMA
(AmbuÒ AuraFlexÔ disposable laryngeal mask). (c) Second Generation LMA (AmbuÒ AuraGainÔ disposable laryngeal mask). (d) i-gelÒ supraglottic
airway. (e) Intubating LMA (LMA FastrachÔ) with, (f) Dedicated tracheal tube (LMA FastrachÔ ETT) and (g) Stabilizing rod.

SADs may be classified as first- or second-generation devices.
The first-generation devices typically provide an airway with a
low pressure (<20 cm water) seal. Second-generation devices
have various modifications to provide a greater seal pressure,
drainage of gastric content, reduce dental damage, or allow
easier endotracheal intubation.
First-generation devices
Laryngeal mask airway (LMA): the ‘classic LMA’ was introduced
into clinical practice in 1988 and has been used in over 500 million
patients. It is made of silicone and has an airway tube (with
connector), an inflatable cuff (mask) and a tube for cuff inflation.
The cuff extends inferiorly to the upper oesophagus, bilaterally to
the pyriform fossae and superiorly to the tongue base. A seal is
formed upon cuff inflation e the manufacturer recommends
inflation to no more than 60 cm water, which can be measured by
manometers or estimated by pilot balloon palpation. Cuff pressure
commonly contributes to sore throat but may rarely cause recur-
rent laryngeal, hypoglossal or lingual nerve damage.
The original classic LMA could be reused 40 times. Following
concerns about possible prion transfer, single-use devices (e.g.
LMA UniqueTM) have since been introduced and these are very
similar physically. LMAs come in a variety of sizes based on
patient weight (Table 1).
An LMA may be used for:
 Elective anaesthesia: either in spontaneous or
controlled, low-pressure (<20 cm water) ventilation in
patients with a low risk of gastric regurgitation.
 Rescue airway device: where FMV or endotracheal
intubation is difficult, worsening or has failed (‘plan C’
of the DAS guidelines).
 Intubating conduit: where endotracheal intubation is
difficult, an LMA may be used to aid passage of a
flexible fibreoptic bronchoscope.
However, they have their limitations, including:
 Aspiration risk: the inflated cuff sits above the larynx
and as such, reflux of gastric content into the lungs is
possible.

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 FUNDAMENTAL PRINCIPLES
LMA sizing
LMA size Patient mass (kg) Maximum cuff
volume (ml)
1 <5 4 airway using the stabilizing rod. An 80% first time success with
1.5 5e10 7 this technique has been reported.
2 10e20 10
2.5 20e30 14
3 30e50 20
4 50e70 30
5 70e100 40
6 >100 50
Table 1
 High-pressure ventilation: in those with poor chest wall
or lung compliance (e.g. obesity), high ventilator pres-
sures may result in gas leak and/or gastric insufflation.
 Periglottic pathology: this impedes adequate placement
of the device (e.g. lingual tonsil hypertrophy).
Flexible LMA: similar to the ‘standard’ LMA in dimensions. The
airway tube is narrower and longer, and wound with spiral wire.
This allows greater flexibility and permits tube repositioning
without mask dislodgement and is useful for head, neck and
dental surgery. It has the same limitations as other LMAs.
Second-generation devices
ProSeal LMA (PLMA): this was the first of the second-
generation devices, introduced in 2000.6 It introduced a num-
ber of modifications that have become typical of this generation,
including a larger modified cuff which permits higher seal pres-
sures, a gastric drainage tube separate from the airway tube and
allowing venting of gastric fluid away from the bowl of the mask,
and a silicone bite block. The higher seal pressure allows venti-
lation with higher driving pressures, while the gastric drainage
port theoretically increases safety by reducing the aspiration risk.
Second-generation LMAs are, however, not advised for use in
patients with a ‘full stomach’ or at aspiration risk secondary to
other factors.
LMA Supreme: a single-use device of very similar design to the
PLMA. It has a significantly angled bend (of nearly 90o) which
allows easier insertion, but can be of some hindrance when used
to facilitate insertion of a flexible fibreoptic bronchoscope.
i-gelÒ: unique in its lack of inflatable cuff; instead, it employs a
thermoplastic elastomer which ‘moulds’ to the anatomical
structures at body temperature in order to form a seal. A gastric
drainage port is also integral to the device.
Intubating LMA (ILMA): specially designed SAD and conduit for
the passage of a tracheal tube with sizes 3e5 available. Its
modifications include a shorter, wider airway tube which has an
attached handle, and an epiglottic elevator bar proximally.
It is designed to be used with a dedicated tracheal tube; a
cuffed, spiral wired, 31cm long tube with a soft, bullet-shaped tip
in sizes of 6.0e9.0 mm internal diameter. The ILMA is inserted
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blind (as with other SADs) and it can be satisfactorily placed with
the patients’ neck in a neutral position so it is useful for patients
at risk of cervical cord damage. The lubricated tracheal tube is
then inserted into the ILMA airway tube and guided blindly into
the trachea. The ILMA can be subsequently removed from the
Tracheal access from above the vocal cords
Gaining access to the trachea from above the glottis usually in-
volves passing a tracheal tube through the vocal cords, typically
using a visual technique with a laryngoscope to view the larynx.
This is distinct from intubation below the glottis (which involves
tracheostomy or cricothyroidotomy). The purpose of a laryngo-
scope is to view the laryngeal inlet and allow visually guided
endotracheal intubation. For the procedure to be successful,
three criteria generally need to be met: a view, alignment of the
airway axes and space for tube passage.
All laryngoscopes suffer the same limitations:
 blood or secretions: degrade or obscure the view
 limited mouth opening/trismus: the mouth must be
able to open sufficiently to accept the device blade and
subsequently, the tracheal tube
 training: effective use requires sufficient practice.
Laryngoscopes can be classified as:
 rigid direct bladed: standard (straight Miller; curved
Macintosh) or modified (McCoy)
 rigid indirect bladed: using a prism (Belscope), mirror
(McMorrow), fibreoptics (BullardTM), or video camera
(McGrathTM)
 intubating conduits: optical (AirtraqTM) or video cam-
era (CTrachTM)
 optical stylets: rigid (BonfilsTM) or malleable
(ShikaniTM).
As with SADs, single-use blades have been introduced to
reduce cross-infection. The initial plastic curved blades were
prone to failure e newer, metal blades are now available.
Flexible fibreoptic bronchoscopes may be used to view the
larynx but are not typically considered laryngoscopes (discussed
below).
Rigid direct bladed laryngoscopes (Figure 2)
These consist of a handle (containing batteries) joined to either a
straight or curved blade. Illumination is provided by a lightsource
in the blade itself or a fibreoptic bundle transmitting light from a
source in the handle. The blade has a spatula, flange and beak of
varying geometry and a contact with the handle at a hinge.
Modifications include a movable tip as seen in the McCoy blade.
To obtain a laryngeal view, the blade is inserted into the
mouth. By manipulating the soft tissues of the upper airway, a
line of sight (LoS) between operator and larynx is obtained and
sufficient space created to allow passage of the endotracheal
tube. Success depends on:
 Patient factors: degree of mouth opening, dentition, neck
mobility, positioning of head and neck, airway swelling
and contamination with blood, secretion or debris.
 Practitioner factors: correct device choice and appropriate
technique
3 Ó 2018 Published by Elsevier Ltd.
 FUNDAMENTAL PRINCIPLES
a b
Figure 2 Rigid direct bladed laryngoscopes. (a) Standard handle with Macintosh size 4 blade. (b) Short (Stubby) handle with Macintosh size 3
blade. (c) Macintosh size 4 blade. (d) Macintosh size 3 blade. (e) McCoy size 3 blade. (f) Miller size 4 blade.
Standard blades are essentially devices designed to lift the
epiglottis. Straight blades (e.g. Miller) achieve this by passing the
beak posterior to the epiglottis and lifting it directly. Curved
blades (e.g. Macintosh) operate by placing the beak in the
vallecula and applying antero-inferior traction to the tongue
base. This applies tension to the hyo-epiglottic ligament and lifts
the epiglottis indirectly. The Cormack and Lehane grading for the
laryngeal view is based on Macintosh blade use and extending
this grading to views gained by other devices, especially video-
laryngoscopes, leads to confusion.
Macintosh laryngoscopy is the most popular technique and is
relatively easy to learn; trained practitioners have a first time
success of over 90%. The most common impediments to success
are:
 Prominent upper teeth: which interfere with the LoS and
increase the risk of dental damage.
 Tongue base pathology: cysts, tumours or lingual tonsils
prevent the beak entering the vallecula.
 ‘Anterior larynx’: the tongue has to be displaced into the
mandibular space to obtain adequate LoS. If the space is
small, the tongue protrudes posteriorly and obscures the
view.
 Floppy epiglottis: this is most commonly seen in infants
and limits curved blade use.
Modified blades for rigid direct laryngoscopy
Polio blade: a curved blade which forms an obtuse, 120 angle
with the handle. Originally used for patients in ‘iron lung’ ven-
tilators, it is now most commonly employed for patients with a
small ‘sternal space’, usually those with large breasts.
The reversed blade: is a ‘mirror image’ version of the standard
Macintosh, designed to displace the tongue rightwards. It is
useful in patients who are in the right lateral position or who
have right-sided pyriform fossa masses.
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c
McCoy blade: a Macintosh variant which incorporates a lever-
operated movable blade tip to enhance epiglottic displacement.
It is useful when neck movement is limited.
Flexiblade: this has a lever which flexes the distal half of the
(curved) blade.
Other direct laryngoscopes exist and are usually variations on
straight or curved blades. They have not shown convincing im-
provements over standard blades in general use.
Rigid indirect bladed laryngoscopes
These devices achieve a laryngeal view either via optics (reflec-
tion by use of a prism, mirror or fibreoptics) or electronic (video)
imaging. Of the two techniques, the latter is far more common in
clinical practice. For completeness, examples of the former are
listed below.
BelscopeTM: a curved blade with a perspex prism to allow indi-
rect LoS.
McMorrowTM: a curved and hinged blade. It is fitted with a
dental mirror, actuated by levers, which gives an upside-down
view.
The BullardTM and UpsherTM: laryngoscopes have curved, rigid
blades and use fibreoptics for illumination and image
transmission.
Electronic (video) imaging
This technique is used by several types of videolaryngoscope and
is increasingly common. In general, a form of digital camera is
housed near the beak of a blade (of varying geometry) and the
image is transmitted to a screen. Examples include: Glidoesco-
peTM; McGrath Series 5TM; McGrath MACTM; CMACTM; AP
AdvanceTM. Videolaryngoscopes (and fibreoptic bladed devices)
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 FUNDAMENTAL PRINCIPLES
usually provide a laryngeal view and can ‘see around the corner’.
While the need for reduced airway alignment allows a better view
to be obtained, there is often an associated reduction in space for
endotracheal tube passage which can hamper intubation attempts.
These devices may be classified as:
 Obligate videolaryngoscopes: The blade geometry is
such that no direct view is achievable and the user
must view the screen (e.g. GlideScopeTM), McGrath
Series 5TM. Usually some form of stylet or bougie is
required (see below). Care must be taken when
inserting this into the mouth since there is a ‘blind spot’
and palatal injury has been described.
 Optional videolaryngoscopes: The curvature of the blade
is less acute and the user may choose to view the larynx
either directly or indirectly (e.g. McGrath MACTM (with
MAC blade; Figure 3). These devices allow training from
direct to indirect techniques and are useful for teaching
airway anatomy to novice anaesthetic trainees.
 Orientating videolaryngoscopes: These devices have a
guiding channel for the tracheal tube in the blade, e.g.
Pentax Airway ScopeTM. By selecting a blade sheath
with a channel, devices from the other two groups join
this set (e.g. McGrath MACTM with X blade).
There is currently no strong data to recommend which device
is generally superior.
Intubating conduits
As with indirect bladed laryngoscopes, these can use either op-
tical or electronic imaging.
AirtraqTM: a single-use device which uses illuminated lenses and
prisms to display the larynx. It has an integrated intubating channel.
CTrachTM: a modified ILMA with a light source and camera
incorporated into the bowl. The image is transmitted to a
detachable screen. It is unique in allowing simultaneous visual-
ization, ventilation and intubation, but is currently unavailable.
Optical stylets7
BonfilsTM: a 5 mm stylet that incorporates fibreoptic illumination
and imaging. The body is straight with a distal curve and is
designed to be loaded with an endotracheal tube. It permits
intubation with minimal neck movement.
ShikaniTM: similar to the Bonfils, but with a malleable tip. This
risks damage to the fibreoptic components.
Figure 3 McGrath MACTM videolaryngoscope.
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Flexible fibreoptic bronchoscopes (FFOB)
These versatile devices can be used for airway inspection, bi-
opsy, toilet and tracheal intubation by oral or nasal routes, under
local or general anaesthesia. They consist of:
 An insertion cord: fibreoptic light and viewing bundles, tip
control elements and working (suction) channels.
 A control body: handle, control lever, eyepiece, and a light-
guide from battery or umbilical (cable).
The classic FFOB is expensive, delicate and needs intense
decontamination. More recently, manufacturers have introduced
single-use, disposable devices. The principles of use are the same
and training is required to master their use and correct patient
preparation. The main limitations are image loss due to blood or
secretions, the inability of patients to tolerate an awake approach
and deficits in practitioner skill.
Intubation with a FFOB involves navigating the upper airway
under direct visualization and inserting the tip of the broncho-
scope into the trachea. Once achieved, an endotracheal tube may
be guided (‘railroaded’) over the body of the bronchoscope.
Alternatively, an in situ SAD may be used as a guiding conduit
for the FFOB, and an Aintree Intubating CatheterTM placed as an
intermediary step (see below).
Tracheal tubes (Figure 4)
The cuffed tracheal tube provides airway patency and protection.
These are typically single-use devices made of polyvinyl chloride.
A ‘standard tube’ consists of:
 A connector of 15 mm external diameter for connection to
breathing circuits.
 The body, marked with a radio-opaque line and centimetre
distance markers from the tip. They also have printed in-
formation on internal (ID) and external diameters. (When
printed, ‘Z29-IT’ refers to the room number where the
decision on biocompatibility, ‘implantation testing’ in
rabbit, was made.)
 A tip, with a left-facing bevelled opening. Some have an
additional opening (a ‘Murphy’s eye’) to allow ventilation
if the main opening is blocked.
Cuffed or uncuffed tubes are available. When present, the cuff
is inflated with air via a pilot tube, balloon and self-sealing valve.
The cuff pressure should be <30 cm water and measured with a
manometer. Most cuffs are of ‘high volume, low pressure
design’, which seek to avoid tracheal wall damage and necrosis.
It should be noted that nitrous oxide can diffuse into the cuff and
increase its pressure. An adequately inflated cuff forms a seal in
the trachea, permitting high pressure ventilation. It also acts to
protect the airways from any aspiration risk.
A variety of tracheal tubes exist, including:
 Reinforced tubes which have a spiral wire to resist kink-
ing. These are often used for neurosurgery and maxillofa-
cial surgery.
 Preformed tubes are moulded to direct the tube away from
the operative site in head-and-neck surgery. Examples
include Polar (north-or-south facing) and RAE (Ring,
Adair, Elwyn) tubes.
 Microlaryngeal tubes are soft walled and cuffed. They are
used for laryngeal procedures where they obstruct the
surgical field of view as minimally as possible.
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 FUNDAMENTAL PRINCIPLES

a e

f
c

d g

Figure 4 Tracheal Tubes. (a) Armoured flexible (MallinckrodtÔ Lo-Contour Reinforced TT). (b) Microlaryngeal (MallinckrodtÔ Microlaryngeal TT
Cuffed). (c) Standard (MallinckrodtÔ Hi-Contour Cuffed TT). (d) Standard Profile Cuff (PortexÒ ProfileÔ Soft SealÒ Cuff). (e) Preformed Polar North
Facing Nasal (PortexÒ Ivory PVC, North Facing, Nasal, ProfileÔ Soft SealÒ Cuff, Polar Preformed). (f) Preformed RAE South Facing Oral
(MallinckrodtÔ Oral RAE TT Cuffed). (g) Laser (MallinckrodtÔ Laser TT Dual Cuffed).

d
b

c b

Figure 5 Lung isolation airway equipment. (a) Left-sided double lumen tracheal tube (RuschÒ). (b) CookÒ Arndt endobronchial blocker (snare loop
for fibreoptic scope). (c) CookÒ Cohen tip deflecting endobronchial blocker (disc controlled flexible tip). (d) Tracheal tube connector for endo-
bronchial blocker-fibreoptic scope-breathing system.

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 FUNDAMENTAL PRINCIPLES
 Laser tubes are ignition resistant and either metal or sili-
cone/metal wrapped. They are used for laser airway surgery.
Some have two cuffs and cuff inflation with saline is advised.
 Thoracic surgery usually requires a technique to provide
lung isolation (Figure 5). Double-lumen tubes have one
lumen to enter one mainstem bronchus, with the other in
the trachea. Alternatively, balloon-tipped guidewires
designed as endobronchial blockers (UniventTM, ArndtTM,
and CohenTM), which are passed through an appropriately
sized single lumen tracheal tube, may be employed.
 Subglottic tubes, such as the Hunsaker (Mon-JetTM) and
the Jet Catheter (VBM) are narrow catheters designed for
laryngeal surgery. They are passed through the glottis and
require high-pressure source ventilation (HPSV). A second
lumen may be used to measure respiratory pressures or
gas composition.
Aids to tracheal intubation (Figure 6)
Stylets: are malleable, coated wire rods which are inserted into
tracheal tubes to bend them and maintain their shape. When a
tight distal curve is formed it is called a ‘hockey stick’. The stylet
should not protrude beyond the tube orifice to avoid causing
tissue trauma.
A tracheal introducer: is a guide for intubation when the
laryngeal view is incomplete or tube passage is problematic. The
standard device is the Portex VennTM, known as a ‘bougie’. It is a
60 cm flexible rod with an angled ‘coude’ tip made of braided
polyester with resin coatings. It can be reused six times. Single-
use devices include the FrovaTM. These devices risk causing
direct trauma to the airways. As they are hollow, adaptors permit
HPSV but barotrauma is a risk.
The Aintree Intubating CatheterTM: is a 56 cm long hollow tube
with adaptors for breathing systems and for HPSV. It can be threa-
ded over a 4.0 mm FFOB or blindly through a SAD into the trachea
allowing a tracheal tube (>7.0 mm ID) to be guided over it.
Airway exchange catheters: are long (83 cm) hollow catheters
used for tracheal tube exchange. Adaptors allow for oxygen
insufflation or HPSV. The catheter tip must remain in the tracheal
lumen; more distal placement risks lung injury, either directly or
from barotrauma with administered oxygen.
Figure 6 Aids to tracheal intubation. (a) CookÒ airway exchange catheter. (b) PortexÒ Venn tracheal introducer (‘bougie’). (c) CookÒ Frova tracheal
introducer. (d) Stylet.
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Retrograde intubation equipment: consists of a cannula or
extradural needle which is used to access the trachea via the
cricothyroid membrane (CTM). An extradural catheter or
guidewire is threaded rostrally and exits the mouth. This can
then be passed through an endotracheal tube or the working
channel of an FFOB to act as an intubation guide.8
Tracheal access from below the vocal cords9
Tracheostomy: is performed when airway patency or protection
via the upper airway is not assured, or as a sedative-sparing mea-
sure in critically unwell patients who require prolonged mechanical
ventilation. It can be done via a surgical (‘open’) approach or by
percutaneous dilational techniques within the critical care unit.
Tracheostomy tubes: are short and curved and many have a
removable inner cannula that permits cleaning. They can either
be of fixed length or have an adjustable flange to alter the depth
of insertion into the neck; this may be required in patients with a
significant amount of subcutaneous tissue in their neck. The
MinitrachTM device has a 4 mm ID and is designed for airway
toileting but it is too small to facilitate adequate gas exchange.
Cricothyroidotomy: involves airway access through the crico-
thyroid membrane. This is a temporary technique with conver-
sion to another form airway control required. There are two
approaches, ‘surgical’ and ‘cannula’. Both are described here,
but data from NAP4 suggests a high failure rate in the emergency
cannula technique, and the latest DAS guidelines solely recom-
mend the surgical approach in emergency situations for front of
neck access (FONA).
This emergency situation, ‘plan D’, is employed when all other
forms of airway control have failed in the ‘can’t intubate, can’t
oxygenate’ scenario. Alternative indications for cricothyroidotomy
include allowing surgical access in laryngeal surgery and as a pre-
caution when airway management is predicted to be difficult.
The (recommended) surgical FONA: approach requires a
scalpel, bougie and a standard endotracheal tube (Figure 7).
Other adjuncts such as a tracheal hook (to maintain tissue
retraction) and forceps (for tracheal dilation) may be useful but
are not essential. Following a transverse stab incision through
the cricothyroid membrane, the scalpel blade should be turned
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 FUNDAMENTAL PRINCIPLES

Figure 7 Equipment for surgical FONA. (a) Scalpel e Number 10 Blade. (b) Bougie. (c) Tracheal tube e cuffed size 6.0 mm ID.

by 90o and used to guide the bougie into the trachea. The
endotracheal tube may then be guided over this and into posi-
tion. Care should be taken to avoid the creation of a false passage
within the tissues and to avoid inadvertent endobronchial intu-
bation. Once correct positioning is confirmed, the patient can be
ventilated as usual with a standard breathing circuit.
sucker. This can have a side port to digitally control flow. Softer
tracheal catheters are also used for endotracheal and nasopha-
ryngeal suctioning. Larger debris and foreign bodies can be
removed with forceps (e.g. Magill forceps), using a laryngoscope
for illumination. Care must be taken to prevent pushing the
debris further inwards. A

The cannula approach: involves piercing the CTM with a needle

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ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 8 Ó 2018 Published by Elsevier Ltd.

Please cite this article in press as: Laurie A, Macdonald J, Equipment for airway management, Anaesthesia and intensive care medicine (2018),
https://doi.org/10.1016/j.mpaic.2018.05.007